1669517868 NPI number — DHHS IHS PHOENIX AREA

Table of content: (NPI 1669517868)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669517868 NPI number — DHHS IHS PHOENIX AREA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DHHS IHS PHOENIX AREA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669517868
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 31001-0699
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91110-0699
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12033 AGENCY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARKER
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85344-7718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-669-2137
Provider Business Practice Location Address Fax Number:
928-669-3131
Provider Enumeration Date:
02/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CUMMINGS
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY PROGRAM SPECIALIST
Authorized Official Telephone Number:
405-951-6086

Provider Taxonomy Codes

  • Taxonomy code: 332800000X , with the licence number:  AZS05857 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0324525 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 02053701 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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